Generalized epileptic seizure in an adolescent idiopathic scoliosis (AIS) patient with syringomyelia after deformity correction surgery

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International

Journal

of

Surgery

Case

Reports

jo u r n al ho m e p ag e :w w w . e l s e v i e r . c o m / l o c a t e / i j s c r

Generalized

epileptic

seizure

in

an

adolescent

idiopathic

scoliosis

(AIS)

patient

with

syringomyelia

after

deformity

correction

surgery

Gultekin

Sıtkı

Cecen

_,

_Deniz

_Gulabi

_,

_Ismail

_Oltulu

_,

_Tolga

_Onay

b_{MedipolUniversity,FacultyofMedicine,OrthopaedicandTraumatologyDepartment,Istanbul34083,Turkey} c_{AdıyamanStateHospital,Adıyaman02200,Turkey}

a

r

t

i

c

l

e

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n

f

o

Articlehistory: Received11April2013 Accepted2May2013 Available online 23 May 2013

Keywords:

Adolescentidiopathicscoliosis Epilepsy

Vertebralposteriorinstrumentation

a

b

s

t

r

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c

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INTRODUCTION:Adolescentidiopathicscoliosisandepilepsyarepathologiesrarelyseentogether.Inthis studywereportanAIScaseweoperatedinwhichepilepsywasseenpostoperatively.Wewantto emphasizetheitemsoneshouldpayattentioninsuchcases.

PRESENTATIONOFCASE:Ina14-year-oldgirlwithAISandconcomitantsyringomyeliaand spondylolis-thesis,posteriordeformitycorrectionandfusionwereperformed.Afterstabilizationthepatientwas dischargedonthe10thdayofdischargeepilepticseizureappeared.

DISCUSSION:Inscoliosissurgery,themechanicstressandbleedingcausedbytheoperationitselfcan causeneurologicalproblemsduetoprimarynervoussysteminjury.Theoperationandbleedingduring andaftertheoperation,pulmonaryandcardiacfunctionalinstability,metabolicimbalancecanbethe causesofepilepticseizures.

CONCLUSION:Epilepsyseenafteramajorsurgerylikescoliosissurgery,canbeeitherasaresultofcentral nervoussystemoriginedvascularandhypoxicproblemsormetabolic.Inourcaseweconcludedthat massivehemorrhagemusthaveinducedepilepsy.Inneurologicconsultationsthecasewasconsidered asanincidentalepilepticpicture.

© 2013 Surgical Associates Ltd. Published by Elsevier Ltd.

1. Introduction

Scoliosisis frequentlyidiopathic,in patientswithadditional neurological problems like syringomyelia complication rate is higher.1

Syringomyeliaisacysticcavitationofthespinalcord accom-panying80%ofthescoliosiscases.Usuallycystslocalizedatthe dorsalaspectofthecentralcanalaresupposedtosqueezemedial nucleargroupsthuseffectinganteriorhorncellsanditisreported thatattheselevelstrunkalmuscularbalanceislost,influencing scoliosis.2,3

Epilepsyaffectsapproximately1%ofthewholepopulationand thoughdifferentetiologicalfactorsaresuggested,certain etiologi-calcausecannotbeobtainedinmostofthecases.Geneticfactors arethoughttoplayaroleintheetiologyof40%ofepilepsycases whichcannotbeexplainedandwhichareidiopathic.4–6_Inepileptic

seizuresthemostcommonseizuresarepartialepilepticseizures.7

Inepilepsyetiology,cellularmetabolicmechanismsalsosharea partandbloodCa2+_{levelsshouldbecloselymonitored.Central} ner-voussystemspaceoccupyinglesionsalsoshouldbekeptinmindin

∗ Correspondingauthorat:SemsiDenizerCad.E5.,YanyolCevizliKavsagı,Kartal, Istanbul34862,Turkey.Tel.:+902164413900/1440;fax:+902163520083; mobile:+905324273133.

E-mailaddress:[email protected](G.S.Cecen).

etiology.Aftermassivehemorrhages,cerebralischemiacantrigger convulsionsattheearlypost-operativeperiod.8,9

Inourliteraturesurveythere isnoreportedcaseofepilepsy afterscoliosissurgeryyetknowntoourknowledge.Inourstudywe reportacaseofrarecomplicationofacaseofwithsyringomyelia aftercorrectivescoliosissurgeryofanAISpatient.

2. Presentationofcase

A14-year-oldfemalepatientwasadmittedwithacomplaintof backpain,low-backpainandcurvatureofhertrunk.Herphysical examinationandradiologicalobservationrevealedthoracolumber scoliosis.Alsoat L5–S1level Grade Ispondylolisthesis, atC4–5 levelnoncompressivecentraldiskprotrusions,thoracal syringo-hydromyeliawasnoted.

Afteroverallinvestigationandplanningcorrectivesurgeryfor scoliosiswasperformedundergeneralanesthesiawithposterior incisionbetweenThorakal2andLumbar3vertebraebydissection ofposteriorelementsandmuscles.Toavoidinjurytothesyrinx withoutusinganosteotome,withthehelpofburrmotorsarticular resectionswereperformed.Spondylolisthesisscrewswereinserted attheconcavesideoftheT5andL1vertebrae.T2–4vertebraewere fixedwithpedicularscrews.Attheconvexsideofthevertebrae pediclescrewswereappliedandinstrumentationwasconcluded. Aftertherodadoptedtothespondylolisthesisscrewsofthe con-cavesidewerepulled,thefixationendedwiththerodappliedto

2210-2612 © 2013 Surgical Associates Ltd. Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.ijscr.2013.05.008

Open access under CC BY-NC-ND license.

Open access under CC BY-NC-ND license.

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Fig.1. 14-Year-oldfemalestandingorthorontgenogramAPgraphy.LenkeTip3A.

Fig.2. 14-Year-oldfemalestandingorthorontgenogramLATgraphy.LenkeTip3A.

Fig.3. 14-Year-oldfemalestandingorthorontgenogrampost-operativeAPgraphy.

Fig.4.14-Year-oldfemalestandingorthorontgenogrampost-operativeLATgraphy.

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742 G.S.Cecenetal./InternationalJournalofSurgeryCaseReports4 (2013) 740–743

Fig.5. MRIscanofthe14-year-oldfemalewithsyringomyelia.

theconvexside.Aftersegmentalderotationisperformedineach vertebralsegment,convexsidewascompressedattheapicalregion and concave sidewas distracted toconcludereduction. During decorticationprocedures,burrmotorwasusedtryingnottoinjure syringomyelia.Allograftwasapplied,drainwasleftatthesurgical woundandtissueswereanatomicallyclosed.Pre-operativeblood losswas2700ml.Aftertheoperation6unitsoferythrocyte sus-pension,2unitsoffreshfrozenplasmawereadministered.Shewas closelymonitoredattheintensivecareunitfor12handsenttothe clinicafterstabilization.Antibioticprophylaxisandwoundhealing took3days’follow-up,andthenthepatientwasmobilized.She wasdischargedafterclinical,radiologicalandlaboratorydatawere normal(Figs.1–5).

On her admittance to the emergency unit with convulsive spasmsand cyanosisonthe10thpost-operativedayhercranial andcervicalMRIimagingwasnotedasnormal.Herexamination andlaboratoryfindingswerenormal;after2months’follow-up epilepticseizurerepeatedand EEGwasperformed.Generalized epileptiformirregularitywasdetected.

Earlyandlatelaboratoryfindingsafterseizurewerecompared betweenblood Ca2+ _{levels and other blood mineral-electrolyte} tests were normal.10,11 _{The transfusion amount of more than}

2000ml is accepted as massive transfusion. In our case pre-operative4units,post-operative2unitsoferythrocytesuspension and 2units of fresh frozen plasma transfusion were adminis-tered.

Inourcasewecouldnotverifyanymetabolicorcentral ner-voussystem pathology to result with epilepticseizures in our work-up.

3. Discussion

Inscoliosissurgery,themechanicstressandbleedingcaused by theoperationitself cancause neurological problemsdue to primarynervoussysteminjury.Besideswesometimeshavetoface morecomplicatedproblemslikeepilepticseizures,operationand bleedingduringandaftertheoperation,pulmonaryandcardiac functionalinstability,metabolicimbalancecanbethecausesof epilepticseizures.12 _{Inearlypost-operativeperiodchangeinCa}

vsMglevels,infection,subarachnoidhemorrhagecanalsocause epilepsy.10,13,14_{DuringAISsurgery2000–2500mlbleedingin}

aver-ageisacceptedasnormal.Thisbleeding cancausehemorrhagic shock.Thehypoxiaduetobleedingcandamagecellularfunctioning inthebraincausingconvulsiveseizures.Massivebloodtransfusion cancausehypocalcemiawhichcantriggerconvulsions.14–19

Inourcasewereportthathypoxiadependingonmassive hem-orrhagecanbethecauseofepilepticseizure.

InAISsurgery torestricthemorrhage,primarilyhypotensive anesthesia,secondarilygentledissectionanddecorticationofthe muscles,controlofbloodloss,rapidbloodtransfusionarenecessary toavoidprobableneurologicalproblems.

In ourcase hemorrhage amountand electrolyte levelswere carefullymonitoredandadequatetimingandtransfusionratesare administeredtoavoidhypoxicinjury.

4. Conclusion

Inliteratureafterscoliosissurgerythisistheonlyreportedcase ofepilepsyyetknowntoourknowledge.Wereportthiscaseto shareourexperiencewithepilepsyprobleminan AIScase and drawattentiontotheimportanceofpatienthistory, monitoriza-tion,andfollow-up.WethinkthatinAISoperations,knowledge abouthypoxic injury and problemsmust beadded to the pre-operativepatientinformationandconsentform.

In thiscase we couldnotdetermineanyfindings toexplain thecauseofepilepsyandconcludedthattheepilepticseizureis miscellaneous.

Conflictofintereststatement None.

Funding None. Ethicalapproval

Writteninformedconsentwasobtainedfromthepatientand herfamilyforpublicationofthiscasereportandaccompanying images.Acopyofthewrittenconsentisavailableforreviewby EditorinChiefofthisjournalonrequest.

Authorcontributions

GultekinSıtkıCECEN:designthestudy,writing;DenizGulabi: writing,review;IsmailOltulu:datacollection;TolgaOnay:data collection.

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